Breast cancer is the second most common form of cancer among women in
the United States and the second leading cause of cancer death in
Yet there are new signs of hope. According to the American
Cancer Society, “death rates from breast cancer have been declining
since about 1990, with larger decreases in women younger than 50. These
decreases are believed to be the result of earlier detection through
screening and increased awareness, as well as improved treatment.”1
Similarly, in Europe, 350,000 cases of breast cancer are diagnosed
annually, yet nearly 90% of them may be cured if detected at an early
Behind these encouraging signs is the technology. Recent
advances in mammography and breast tomosynthesis, along with emerging
techniques in molecular imaging, are enabling physicians to detect
smaller lesions at earlier stages in disease development.
The gold standard
digital mammography (FFDM) remains the gold standard in breast
screening, yet the technology has its limitations, particularly in women
with dense breasts, where overlapping tissue makes cancer detection
more difficult and creates greater risks for that patient population. A
study found that extensive mammographic density is strongly associated
with the risk of breast cancer detected by screening or between
FFDM, however, is evolving and
manufacturers continue to build on its capabilities. The MAMMOMAT
Inspiration FFDM system by Siemens Healthcare, for example, provides
screening, diagnostic, and stereotactic biopsy capabilities in a single
system. To match breast density and thickness, the unit offers 3
Another concern is radiation
exposure in FFDM, especially since exams are annual. Philips
Healthcare’s MicroDose Mammography FFDM system combines a lower dose as
compared to other FFDM solutions with a warm, padded, and breast-shaped
contoured design for all around enhanced patient comfort.
emerging technique within FFDM is contrast-enhanced spectral mammography
(CESM) technology, which is used to assess the extent of breast
cancers. In a study presented at RSNA 2011,3 researchers
compared the diagnostic accuracy of CESM and MRI in assessing the extent
of breast cancers. This preliminary study showed that CESM performs
with good diagnostic accuracy with sensitivity slightly inferior to and
specificity slightly superior to those of MRI.3
Healthcare’s newly FDA-cleared SenoBright system offers CESM technology.
The system combines 2 high-quality images in the same orientation for
each of the standard CC and MLO views. The first image exposure uses
standard mammography parameters, while the second shows
contrast-enhanced areas with the background tissue signal suppressed.
The images together create a final view where signal from the normal
tissue is removed and where contrast appears very distinctly. CESM may
be useful as an adjunct exam to clarify equivocal lesions.
system specifically designed for women with dense breasts is the somo•v
Automated Breast Ultrasound (ABUS) system by U-Systems. ABUS is
FDA-cleared for diagnostic use as an adjunct to mammography, but it is
also scheduled for FDA premarket approval (PMA) review for a breast
cancer screening indication. This would establish ABUS as an adjunctive
screening breast ultrasound tool for women with dense breasts.
A new dimension
One of the most anticipated developments in
breast imaging has been the introduction of tomosynthesis, a
3-dimensional mammogram that takes multiple images of the breast. By
adding a new dimension in breast cancer detection, tomosynthesis
provides a clearer view through the overlapping structures of breast
tissue, and may detect lesions missed by standard 2-dimensional
Among the benefits of tomosynthesis: It improves
radiologists’ ability to screen for and detect potential breast cancers;
it helps to pinpoint the size, shape, and location of abnormalities;
and it can help distinguish harmless abnormalities from malignancies,
leading to fewer callbacks and less anxiety for women.4 In
fact, a retrospective observer study compared the diagnostic performance
of FFDM with that of digital breast tomosynthesis and found that
tomosynthesis may result in a substantial decrease in recall rates.5
tomosynthesis solution is the Selenia Dimensions digital breast
tomosynthesis system (Dimensions 3-D). Selenia Dimensions allows
radiologists to offer their patients conventional 2-dimensional digital
mammography and a 3-dimensional tomosynthesis exam in a single
Other manufacturers have developed different
approaches to 3-dimensional mammography. Providing a unique
configuration to a 3-dimensional mammography system is the Giotto Image
3D and 3DL Digital Mammography Systems (3DL) by Giotto USA, which
received FDA 510(k) clearance last November. The system has a
ring-shaped, tilting gantry designed for easier, face-to-face patient
positioning. The Giotto provides 2 systems in one by adding the optional
biopsy digital stereotactic biopsy device, combining mammography and
prone stereotactic biopsy all in one unit.
Systems U.S.A offers its works-in-progress solution to 3-dimensional
breast screening with 3D Digital Mammography. Pairs of stereo images of
the breast are acquired and then viewed by combining a 3-dimensional
review workstation and dedicated glasses designed to present
3-dimensional breast images.
To ease the adoption of new
mammography techniques in clinical workflow, Sectra recently introduced
its Breast Imaging PACS workstation, a solution that supports all
imaging modalities, including breast tomosynthesis images. The breast
images are automatically aligned and displayed side-by-side in the same
size and dimension, a useful feature for combined 2-dimensional and
Molecular imaging clears some hurdles
screening mammography, especially when combined with ultrasound, has
shown the ability to detect nonpalpable breast cancer, lesion detection
in high-risk patients with dense breasts remains a serious obstacle. Yet
molecular imaging may likely clear that hurdle. New studies show
improved detection with techniques such as breast-specific gamma imaging
(BSGI), also referred to as molecular breast imaging; positron emission
mammography (PEM), and more recently, combination PET and MR imaging.
benefit of BSGI is it is less susceptible to breast density, since the
radioactive tracer used in the procedure has a high affinity for
metabolically active tumors. A study found BSGI had the highest overall
sensitivity (91%) for breast cancer detection, significantly higher than
that of mammography and ultrasound, 74% and 84% respectively.6
system blazing a trail in BSGI is the Dilon 6800, a high-resolution,
small field-of-view gamma camera. The system acquires images of the
metabolic activity of breast lesions through radiotracer uptake.
recently available BSGI technology is the GE Discovery NM 750b scanner.
The system features dual detectors with cadmium zinc telluride (CZT)
technology for improved sensitivity and resolution.
important emerging technology is positron emission mammography (PEM).
Naviscan offers a high-resolution positron emission tomography (PET)
scanner designed to provide a view of the location and the metabolic
phase of a lesion in breast tissue, and assist doctors in distinguishing
between benign and malignant lesions. In a study comparing PET to
whole-body PET/CT of the breast, PEM had higher imaging sensitivity than
PET/CT, particularly in small tumors. The results suggest PEM may be
used to diagnose and characterize small lesions as a supplementary
imaging modality for PET/CT.7
Combining PET/MRI for breast
striking development in breast imaging is combining MRI and PET images
to acquire high-resolution anatomical and functional information. Fusing
data can assist in detecting small lesions and assessing metastatic
In an ongoing trial, researchers8 are
comparing a prototype breast PET ring simultaneously with the Aurora
Dedicated Breast MRI system to clinical PET on patients with suspected
or biopsy-proven breast cancer. With the goal of evaluating the
feasibility of simultaneous PET-MRI in the clinical setting, the
researchers expect MRI with the breast scanner insert to deliver images
with more precise and pinpoint resolution.
With these promising
developments in breast imaging, there is hope that the second most
common form of cancer among women will soon rank a lot lower.
- Breast Cancer. American Cancer Society.
Last Revised: 01/06/2012. Accessed February 28, 2012.
- Boyd FM, Guo H, Martin LJ, et al. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 2007;356:227-236.
- Dromain C, Canale S, Bidault F , et al. Value of contrast-enhanced
spectral mammography (CESM) in women with newly diagnosed breast cancers
compared to MRI: Preliminary results. Presented at: Radiological
Society of North America 2011
Scientific Assembly and Annual Meeting; November 27- December 2, 2011
Accessed March 2, 2012.
- Massachusetts General Hospital. Imaging. 3D Mammography
Accessed March 2, 2012.
- Gur D, Abrams G, Chough D, et al. Digital breast tomosynthesis: Observer performance study. AJR Am J Roentgenol. 2009;193:
- Weigert JM, Bertrand ML, Lanzkowsky L, et al. Results of a
multicenter patient registry to determine the clinical impact of
breast-specific gamma imaging, a molecular breast imaging technique. AJR Am J Roentgenol. 2012;198:W69–W75.
- Eo JS, Chun IK, Paeng JC, et al. Imaging sensitivity of dedicated positron emission mammography in relation to tumor size. Breast. 2012;21:66-71. Epub 2011 Aug 25.
- The collaborative effort is between Brookhaven National Laboratory,
Upton, NY; Aurora Imaging Technology, Inc., North Andover, MA; Stony
Brook University, Stony Brook, NY; and Taipei Medical University
Hospital, Taipei, Taiwan. This work was also supported by the U.S.
Department of Energy.